NFL Evolution will feature a guest columnist every Tuesday, each with a different viewpoint of player health and safety from the youth level to pro football.
By Dr. Joseph F. Waeckerle, NFL Evolution columnist
Concussion injures brain cells and their systems so the treatment is designed to heal those cells/systems as completely as possible. Each concussed person is unique and requires an individualized plan of management. However, knowledgeable health care professionals base their treatment on the principle of "brain and body rest".
Brain cells/systems require oxygen, energy substances, and blood flow to function properly. An estimate of brain use of these requirements is 20 percent of body's daily needs, a considerable amount. A concussion will result in an increase cellular demand for these requirements while trying to heal. At the same time, blood flow and energy metabolism to the injured cells are disturbed causing the brain to be more vulnerable.
Also, there is now evidence that suggest that improper management of recovery may lead to increased risk of subsequent concussions, prolonged symptoms/signs, and short- and long-term complications. Therefore, the goal of concussion treatment is to decrease the normal demands on brain cell/system function so to shift available requirements more to promote recovery.
The concussed person will first be advised to minimize all activities that stimulate the brain, most especially cognitive (thinking) activities. This includes no exposure to work or school demands, reading, TV, computers, cell phones, music or loud sounds, social activities, or driving.
There are no validated benchmarks to gauge mental recovery so health care professionals use a decrease in the patient's symptom/signs, notably headache, nausea, memory problems, and frustration tolerance, to indicate improvement. As symptoms/signs lessen, the patient's mental activities may be carefully increased with the goal of the patient being able to perform mental activities without symptoms/signs.
After the concussed patient is permitted to return to work or school, they still need careful monitoring of their progress. Once the patient experiences no symptoms/signs with mental activities and normal daily activities, they can begin physical activities under guidance.
Physical activities substantially increase the demands for oxygen, energy substances, and blood flow to active muscles and other vital organs. These new demands "steal" from the brain's requirements which may retard healing or cause further injury to brain cells. Graduated physical activities can be advanced according to a return-to-play protocol commonly used to monitor recovery.
If the prescribed activities cause the re-emergence of concussion symptoms/signs, then the patient needs to rest. Once symptom/sign free for at least 24 hours, the patient may attempt that activity again.
There are currently no medications that can promote the recovery of a concussed person. Knowledgeable health care professionals can prescribe medications to treat difficult or prolonged symptoms. However, medications may mask symptoms/signs, give a false sense of improvement, and alter findings of cognitive testing potentially resulting in mismanagement if used inappropriately.
Complete recovery of a concussion is mandatory prior to return to play in any sport.
Recovery is defined as:
- Symptom/sign free at rest and with activities
- Normal physical and neurological exam
- Normal cognitive testing
- Normal balance testing
- The ability to participate at the same competitive level of physical activity in his or her sport as prior to the concussion without any difficulties
A competent health care professional should certify that the patient is fully recovered prior to competitive participation.
Dr. Joseph F. Waeckerle is clinical professor of emergency medicine at the University of Missouri-Kansas City School of Medicine. He also is editor emeritus of Annals of Emergency Medicine. He has practiced Emergency Medicine and Sports Medicine and has been a team physician at the grade school, high school, college, and profession level for over 30 years. He currently serves on the NFL Head, Neck, and Spine Injury Committee and the Mackey White Brain Injury Committee of the NFL Players Association.
